CONSENT TO LACTATION CONSULT & FINANCIAL AGREEMENT

I understand the following: The lactation consultant is an allied health care provider and responsible for evaluating and recommending a care path to resolve or improve breastfeeding issues. A lactation visit includes a detailed history of mother/infant, an assessment of maternal/infant anatomy, observation of a feeding for evaluation of technique and effectiveness of feeding, and recommendations for management to improve and/or resolve breastfeeding related issues. All clients are provided with a written and/or oral care path to improve breastfeeding concerns. The client and the lactation consultant each have responsibilities in this path. Resolution of a breastfeeding problem often takes several days or weeks and may require a change in the original recommended care path at some point.

I understand that I am responsible for informing the lactation consultant of changes I feel are necessary in the care plan at the time of the visit or during the course of follow-up communications. Contact during the time following the lactation visit is crucial and considered an extension of your visit. I will be given contact information to report progress or to communicate continued problems or concerns. I understand it is my responsibility to call the IBCLC with progress reports, questions or concerns.

I give my consent for the lactation consultant to work with me and my baby during this consultation and after for my breastfeeding issues. This consent is for in-person visits, as well as phone conversations, and any information sent/communicated by e-mail, mobile phone, fax, SMS text messages, and/or private social media. I understand that electronic/cellular forms of communication may not be encrypted/secure. I understand that email and text are not secure means of communication, and give my permission for Lactation Services of Westport to send and receive texts and emails that may contain my Personal Health Information (PHI). When Lactation Services of Westport comes to my home, I understand the provider will be using GPS or an app such as Waze or Google Maps to get directions.

I understand any change from my physician’s recommendations should be discussed with the physician. Health care issues of a medical nature MUST be discussed with a physician.

I understand a partial or follow-up visit is sometimes necessary. I understand that breastfeeding supplies and/or breast pumps may be recommended as effective management of specific situations. Only effective breastfeeding equipment will be recommended.

I authorize the lactation consultant to release any information acquired in the evaluation and/or management of myself and/or my child to our health care providers, referring physician, referring lay breastfeeding counselor, and/or our insurance company upon request. I understand the lactation consultant may contact my physician or my child’s physician if the lactation consultant feels it is necessary to consult with the physician.

I give my consent for the lactation consultant to use clinical information and any photographs obtained during our sessions for conferring other health care providers and education of mothers about lactation. I won’t be identified in any way, but aspects of my situation may be described and discussed.

I have received a copy of the lactation consultant’s HIPAA Privacy Practices or understand it is available on lactation consultant’s website.

I understand the lactation consultant is a provider on a limited number of insurance plans and will only bill my insurance if the lactation consultant is contracted as an in-network provider with my plan. All services provided for insurance plans for which the lactation consultant is NOT a provider are fee for service at time of service.It is my responsibility to pursue reimbursement for lactation services from my insurance company when the lactation consultant is not an in-network provider on my insurance plan, in which case, full or partial reimbursement is not guaranteed.